Name and surname

Name Surname

E-mail*

phone number*

Date of birth*

Mese/month day year

GENDER*

male female

CITIZENSHIP*

SMOKER*

yes no

DRIVER*

yes no

WHAT COUNTRY DO YOU WANT TO GO*

CAN YOU SWIM*

yes no

CHILDCARE EXPERIENCE*

YES NO

Summarise your overall experience with children, please

WHAT IS YOUR RELIGION , PLEASE?

PROGRAM TYPE*

EARLIEST START DATE*

PROGRAM LENGHT*

IS YOUR CRIMINAL RECOPRD EMPTY?*

yes no

Studies performed

Do you have any current/pre- existing medical conditions?*

yes no

Do you have any allergies (include pets)?*

yes no

Are you currently taking any medication*

yes no

Are you currently receiving , or have you received, any psychiatric or psycholog ical treatment?*

yes no

are you on particular diet?*

yes no

Would you agree to undergoing a test for aids/HIV?

yes no

CAN YOU ACCEPT A SINGLE PARENT?

yes no only with a single mother

WITH A DIFFERENT RELIGIOUS BELIEFS TO YOU?

yes no

WITH A CHILD WITH DISABILITIES?

yes no

MANY FAMILIES HAVE PETS , CAN YOU CACCEPT LIVING WITH

dog cat RABBIT

COULD YOU CONSIDER TO SHARE OCCASIONALLY YOUR ROOM WITH THE CHILDREN ?

yes no

YOU HAVE EXPERINCE WITH

CAN YOU DRIVE FOR THE FAMILY ?*

yes no

Please leave some notes can be usefull to your host family

I agree with the Privacy Policy of this site

YES

Tutor-Aupair-DemiPair-Nanny

Family Preference